Citation Nr: 19164013 Decision Date: 08/19/19 Archive Date: 08/19/19 DOCKET NO. 15-12 470 DATE: August 19, 2019 ORDER Entitlement to service connection for sleep apnea, to include as secondary to service-connected post-traumatic stress disorder (PTSD), is granted. FINDING OF FACT The Veteran’s sleep apnea is proximately due to or the result of his service-connected PTSD. CONCLUSION OF LAW The criteria for service connection for sleep apnea, to include as secondary to PTSD, are met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1964 to July 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Board requested an outside medical opinion to further develop the Veteran’s case. A specialist’s opinion was received that same month. In May 2019, the Veteran indicated that he had no further argument or evidence to submit and requested that the Board immediately proceed with the adjudication of the appeal. Service connection for sleep apnea Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303(a) (2018). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2018). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310 (2018); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Veteran alleges that he has sleep apnea that is secondarily related to his service-connected PTSD. See July 2014 Notice of Disagreement. This appeal has also been developed on a direct theory of entitlement. However, since the benefit sought is granted on a secondary basis, the Board will not discuss whether the Veteran’s sleep apnea had onset in service or is otherwise directly related to service. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). In March 2013, the Veteran underwent an overnight polysomnography VA. The test revealed obstructive sleep apnea. A follow-up polysomnography in November 2013 showed a diagnosis of mixed sleep apnea. Second, the Board finds that the Veteran’s sleep apnea is proximately due to or the result of his service-connected PTSD. 38 C.F.R. § 3.310. An October 2013 VA treatment record noted that the Veteran should hold off on taking medications such as Clonazepam, as it could worsen his sleep disordered breathing. The Veteran had been taking Clonazepam to improve his sleep, which was impaired by his service-connected PTSD in pertinent part. In a November 2018 brief, the Veteran’s representative cited to a recent study that showed an increased risk of sleep apnea for those veterans with PTSD. Against the Veteran’s claim is a November 2014 VA treatment note that documents a VA physician explaining that a cause and effect relationship between the Veteran’s sleep apnea and PTSD had not been established. Notwithstanding the November 2014 VA treatment note, and because of the evidence of record suggested that a secondary relationship may have existed between the Veteran’s sleep apnea and his service-connected PTSD, the Board requested a specialist’s opinion in December 2018. The December 2018 opinion by Dr. SM found that it was at least as likely as not that the Veteran’s sleep apnea was proximately due to or the result of his service-connected PTSD, to include any associated medications. Dr. SM explained that, although there was no evidence to establish a direct causal relationship between PTSD and obstructive sleep apnea, research did suggest that there is a higher prevalence of obstructive sleep apnea in Veteran’s with PTSD. The doctor also noted that medical research showed mechanisms to suggest PTSD as a cause for obstructive sleep apnea. That is, the research reported a highly increased prevalence of comorbid behavioral and medical sleep disorders in trauma patients. The authors of these studies had suggested an arousal-based mechanism initiated by posttraumatic stress, promoting obstructive sleep apnea development in a trauma survivor. The doctor further explained that Clonazepam can exacerbate sleep apnea, as benzodiazepines not only weaken the muscles that affect the airway, but they also prevent patients from arousing fully to open the airway. Dr. SM had reviewed one of the Veteran’s examination reports conducted by his ENT physician, and explained that the Veteran’s anatomy leaves him more susceptible to obstructive sleep apnea when treated with medications that relax the muscles. In addition to opining that the Veteran’s sleep apnea was proximately due to or the result of his service-connected PTSD, Dr. SM also opined that the Veteran’s sleep apnea was aggravated by PTSD. The Board finds that the portion of the opinion that finds that sleep apnea is proximately due to or the result of the Veteran’s service-connected PTSD is adequate. It is supported by sound rationale and reflects consideration of the Veteran’s medical history. As such, the opinion is highly probative. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in determining probative value of a medical opinion is whether the examiner was informed of the relevant facts); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). (Continued on the next page)   The December 2018 opinion is the only evidence of record that persuasively addresses the question of a link between the Veteran’s service-connected PTSD and his obstructive sleep apnea. In making this finding, the Board acknowledges the November 2014 VA treatment note documenting that a cause and effect relationship between the Veteran’s sleep apnea and PTSD had not been established. However, the VA treatment note contains no supporting explanation and is outweighed by the December 2018 outside medical opinion by Dr. SM. Because the probative evidence of record demonstrates that the Veteran’s sleep apnea is proximately due to or the result of his service-connected PTSD, service connection is warranted on a secondary basis. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Steve Ginski, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.